• Consent to Evaluate and Treat a Minor

    Consent to Evaluate and Treat a Minor

    www.boundlesshope.net - 813.219.8844

  • I *, as the parent/legal guardian of*. DOB   Pick a Date*   consent for the evaluation and treatment of this minor and I hereby certify that I have the legal right to seek counseling treatment for minor(s) in my custody and give permission to Boundless Hope* to provide treatment to my minor child(ren).       
    *Boundless Hope is defined as any and all Boundless Hope clinical staff, whether 1099 contracted or W2 staff.

  • If I have sole decision-making capacity to obtain counseling services for my minor, I will provide the appropriate court documentation to * prior to or at the initial session.

  • Additionally, by submitting this form and signing below I attest that any existing documentation, whether a temporary or permanent  order, has been uploaded above. If I fail to upload existing documentation and am found in violation of an existing legal order, I release Boundless Hope LLC from any and all legal responsibility related to the provision of care for the minor listed above.

    Knowingly withholding accurate legal parenting orders will likely result in termination of care.  Referrals will be available upon request.

  • Consent for the evaluation and treatment of this minor.

    By voluntarily signing below, I understand that my child, although a minor, is legally and ethically given total confidentiality with the exception being those circumstances discussed on consent to treatment form which are danger to self, danger to others, or being endangered by others. 

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  • If treatment is for a non driving minor, it is REQUIRED that the designated responsible adult, remain on site at Boundless Hope for the duration of treatment. If I permit anther adult to transport my child, their name and relationship to minor is listed below.

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